JSSN_vol25i2-cut.pdf


www.jssn.org.npJournal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

Abstract

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Every year, more than 200 million surgeries are performed around the 
world, and recent statistics show that adverse event rates for surgical 
pathologies remain unacceptably high, despite several national and 
global patient safety initiatives over the last decade. Patient safety 
is diverse and highly complicated in nature, with several critical 
components. Although concern for patient safety is fundamental in health 
care practice, its transition into knowledge is comparatively recent, and 

patient concerns and risk factors in surgical subspecialties. All surgical 
practitioners and health care organizations must therefore become better 

in endeavors to integrate patient safety measures in daily practice, and 
foster a patient safety culture. The purpose of this review article is to 
outline patient safety in surgical techniques that should be adopted and 
implemented.

Keywords: Patient safety; Quality; Health professions; Surgery.

Review article

Patient Safety and organizational Safety Culture in Surgery: A Need 
of an Hour in the developing countries
Sunil Basukala1, Sujan Bohara2, Anup Thapa1, Aashish Shah3, Soumya Pahari4, Yugant Khand4, Ojas 
Thapa4, Ayush Tamang4,  Bivek Bhagat4, Bikash Bahadur Rayamajhi1

1Department of Surgery, Shree Birendra 
Hospital, Chhauni, Kathmandu, Nepal.
2 Department of Surgery, Nepal Mediciti 
Hospital, Lalitpur, Nepal
3 Department of Anesthesia and Critical 
care Medicine, Shree Birendra Hospital, 
Chhauni, Kathmandu, Nepal.
4 Department of Surgery, Nepalese Army 

Sanobharyang, Kathmandu, Nepal.

Dr. Sunil Basukala,
 Assistant Professor, Department of Surgery, 
Nepal Army Institute of Health Science 

Email: sunil.basukala@naihs.edu.np

None

None

Not applicable

Basukala S, Bohara S, Thapa A, Shah A, 
Pahari S, Khand Y et al. Patient safety and 
organizational safety culture in surgery: a 
need of an hour in the developing countries. 



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np

Introduction 
Health care systems are under growing pressure to create 

events. The development of a patient-safety culture is 
critical in a systems-based approach to patient care and is 
the administrative focus of many surgical departments.1 
The recent surgical malpractice crisis, which revealed 

might result from public broadcast of a sentinel occurrence, 
has stimulated the promotion of patient safety. Errors in 
the operating room, in contrast to other medical settings, 
can be particularly devastating, with potentially high-

such as operating in the wrong location, performing the 
wrong procedure, forgetting sponges, unchecked blood 
transfusions, mismatched organ transplants, and unnoticed 
allergies, can be alleviated through better communication 
and safer hospital systems.2 

as morbidity and death, the healthcare environment is 
seen as a high-risk setting, and health care services as a 
high-hazard sector. Damage, however unforeseen, has 

3, 4 Patient 
safety is embedded in the practice of medicine and is a 
serious concern. However, it is only recently that it has 
been transformed into a specialized body of knowledge, 

care practitioners, health managers, and policymakers 
has begun to evolve. To err is human: establishing a safer 

Institute of Medicine released in 1999, highlighted the 

due to preventable medical errors. These medical errors 
are frequently the consequence of human error, and they 

organizational safety culture.5

Terminologies
Patient safety

or accidents associated with them.
Health risk Management

claims, and cause unnecessary economic losses to health care providers
Adverse event

Includes errors, accidents, delays in care, negligence, complications associated with treatment, etc. It 

an adverse event is not preventable does not imply that we should be unprepared to act promptly and 
appropriately if it occurs.

Error

should be avoidable, the repetition of similar acts, in combination with organizational failures, makes this 

An event that almost causes harm to a patient, and that is avoided by luck or by an act at the last moment.

and reminds the practitioner of the allergy.

the prescription of drugs, about seven times more incidents than complete adverse events are estimated 
to occur.

Accident

Negligence
omission of minimal precautions, or neglect.

Safety culture
skills, and patterns of behavior, which lead to commitment, style, and ability in the management of the 
health and safety of an organization.
Those organizations with a positive safety culture are characterized by communication based on mutual 

prevention.

Table 1. Common terminologies related to patient safety

Basukala S et al



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np

The public outrage caused by the disclosure of these 
numbers impelled the problem of patient safety to the 
top of the priority lists of health professionals, managers, 
and hospital administration. As a result, patient safety 
has become a primary concern for everyone involved in 
health care.  The goal of this review paper is to provide an 
overview of patient safety and organizational safety culture 

care.

PATIENT SAFETY
Patient safety is perceived as the provision of safe health 
care or the protection of patients from harm by health care 

Although both the patient and the practitioner are inherently 

and organizational aspects must also be acknowledged. 
Patient safety, though relatively a new discipline, has as its 
main objectives to facilitate the avoidance of preventable 

associated with health care and to limit the impact of 
inevitable adverse events.1

of a common terminology. To overcome this problem, 

Table 1

patient safety based on the International Patient Safety 
8-15

Patient safety also focuses on the analysis of the 
characteristics of health-care systems and on the 

promote an adverse event to occur while providing care. 
The potential latent risks in a system are vast, including 

slippery when it is wet, the necessity that personnel work 

information is transferred between professionals. Typically, 
an undesirable outcome arises when many latent risks 

systems failure model.  To varying degrees, every phase in 
a process has the potential for failure. The ideal system is 
analogous to a stack of Swiss cheese slices. The holes in the 

represents a "defensive layer" in the process. An issue may 

locations, the problem is contained. Each layer would act 

outcome. The greater the number of defenses and the fewer 
and smaller the holes, the more likely you are to detect 
and prevent errors.11 The Swiss cheese model of accident 
causation illustrates that if hazards are aligned and levels 

Figure 1

PATIENT SAFETY IN SURGERY 
For more than a century, surgical treatment has been a vital 
component of global health care. The impact of surgical 

the incidences of traumatic injuries, malignancies, and 
cardiovascular disease continue to rise. Every year, an 
estimated 234 million major procedures are conducted 
around the world, equating to one operation for every 25 
people alive. However, surgical services are unevenly 

saved and disability avoided, access to high-quality surgical 
care remains a serious issue in much of the world.

Surgery is frequently the sole treatment that can alleviate 
impairments and lower the mortality risk from common 

undergo surgical treatment for severe injuries, another 10 
million for pregnancy-related problems, and 31 million 

public health implications.21 According to research, 

surgical procedures in developed nations, with permanent 

surgery in underdeveloped countries.22 The issue of surgical 
safety is well known around the world. Studies in wealthy 
countries demonstrate the scope and pervasiveness of the 
problem. Poor infrastructure and equipment, unreliable 
supply and drug quality, inadequacies in organizational 

capacity and training, and chronic underfunding all 
contribute to the issues in developing countries. As a result, 

Figure.1. Swiss Cheese Model: A) Hazards are not aligned 
with the “holes” in the levels of defense, therefore, accidents 
are less likely to occur. B) Hazards are aligned and levels of 
defense do not lie between, therefore accidents can occur.

Patient Safety and organizational Safety Culture in Surgery: A Need of an Hour in the developing countries



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np

surgical treatment has the potential to save the lives of 
millions of people around the world. 

for Emergency and Essential Surgical Care and the 

Safety Challenge, Safe Surgery Saves Lives, focuses on 

for Patient Safety began work on this challenge.28 The 
purpose of this challenge is to improve surgical care safety 
worldwide by creating a core set of safety criteria that can 

an agreement on four areas where major improvements in 
surgical safety may be realized. These are: surgical site 
infection control, safe anesthesia, safe surgical teams, and 

Table 2 29-31

The nature of the challenge Teamwork, safe anesthesia, 
and prevention of surgical site infection are fundamental 
to improving the safety of surgery and saving lives. Basic 
issues of infrastructure and the ability to monitor and 
evaluate any changes instituted must be considered and 
addressed .30 

The conventional framework for safe intraoperative care in 
hospitals consists of a routine series of events - preoperative 
patient evaluation, surgical intervention, and preparation 
for proper postoperative care - each with its own set of 

the procedure to be performed, checking the integrity of 
the anesthetic machine and the availability of emergency 
drugs, and ensuring proper preparedness for intraoperative 
occurrences are all interventions that can be made during the 
preoperative phase.32 Appropriate and cautious antibiotic 
use, the availability of critical imaging, appropriate patient 

surgical judgments, meticulous surgical technique, and good 
communication among surgeons, anesthesia professionals, 

operation. Following the procedure, a clear plan of care, an 
understanding of intraoperative events, and a commitment 
to high-quality monitoring may all help to strengthen the 
surgical system, increasing patient safety and improving 
results. There is also an acknowledged requirement for 

proper lighting and sterilization equipment. Finally, safe 
surgery necessitates continuous quality assurance and 
monitoring.33-35

ORGANIZATIONAL SAFETY CULTURE
The organizational safety culture is a critical part of 

regarded as an important aspect of service quality. It has 
even been proposed that patient safety begins with the 
implementation of a safety system at the organizational 
level, and that clinical error in acute-care hospitals can 
only be addressed by creating a safety culture.  A safety 

group values, attitudes, perceptions, competencies, and 
patterns of behavior that determine the commitment to, and 

or assumptions that underline how people perceive and act 
upon safety issues within their organizations."15 A culture 

all activities of health professionals, the main objective of 
which is to avoid the occurrence of unnecessary damage to 

healthcare.38
"culture of blame." It does not look for individuals on whom 

Finally, and fundamentally, it is a culture that compels us 

our colleagues so that everyone can learn from them.  

create a climate of patient safety as an organizational goal 
and a priority, the concepts of patient safety culture and 
safety climate and their implications for health care and 
organizations must be correctly understood by everyone 
involved in health care.40-42

Surgical resources and environment
Trained personnel, clean water, a consistent light source, 

equipment, and sterile instruments
Prevention of 
Surgical Site 
Infection

Safe Anesthesia Safe Surgical 
Teams

Hand washing Presence 
of a trained 
anesthesiologist

Improved 
communication

Appropriate and 
judicious use of 
antibiotics

Professional 
anesthesia machine 
and medication

Correct patient, 
site, and procedure

Antiseptic skin 
preparation

Safety check Informed consent

Atraumatic wound 
care

Availability of all 
team members

Instrument 
decontamination 
and sterility

Heart rate 
monitoring

Adequate team 
preparation and

 Blood pressure 
monitoring

Planning for the 
procedure

Temperature 
monitoring patient allergies

Measurement of Surgical Services
Quality assurance
Peer review
Monitoring outcomes

Table 2. Four areas of major improvements needed for 
surgical safety 

Basukala S et al



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np

Success in establishing a safety culture, with associated 
practices, may depend on prior success in achieving 
unidirectional, positive change in attitudes in order to 

evidence-based care delivery, communication, learning, 
and being just and patient-centered as important domains 

institutional culture for safety survey highlighted design 
improvements in health care, strategic planning, learning 
from errors, commitment to leadership, documenting 
and improving patient safety, encouraging and practicing 
teamwork, detecting possible risks, and employing 
procedures for reporting and analyzing adverse events and 
assessing improvements as relevant.

to the establishment of a safety culture and quality 
improvement, open and transparent disclosure principles, 
health professional human resources crucial to ensuring 

institutions involved in patient safety, national patient 
safety accountability initiatives, and collaborative team 

as relevant to patient safety were: making patient safety 
everyone’s priority; teamwork; valuing individuals; open 
communication; learning, and empowering individuals. 

a "safety atmosphere" and predicting measurements of 
patient safety, as well as cultivating a non-punitive, open, 
and stimulating health care culture.

A safety culture is also suggested in order to demand the 

proactive. Because a supportive culture of patient safety is 
considered vital for enhancing patient safety, organizations 

measures related to patient safety, develop tools, and 

work and culture.41-45

Conclusion 
Current surgical safety, guidelines and checklists are 

issues and risk factors in various surgical subspecialties. As 
a result, it is critical for all surgical practitioners and health 
care organizations to become more aware of the overall 

apply patient safety measures in everyday practice, and to 
develop a patient safety culture. The purpose of this review 
paper is to outline patient safety in surgical techniques that 
should be implemented and followed for safe patient care. 

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www.jssn.org.np

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